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Objective

This document provides interim guidance for protection of persons involved in activities to control and eradicate outbreaks of avian influenza among poultry in the United States. Activities that could result in exposure to avian influenza-infected poultry include euthanasia, carcass disposal, and cleaning and disinfection of premises affected by avian influenza. This interim guidance, developed in cooperation with the U.S. Department of Agriculture (USDA), should be considered complementary to avian population disease control and eradication strategies as determined by the state government, industry, or the USDA. These guidelines will be updated as necessary.

Background: Avian Influenza

Birds that are infected with avian influenza viruses can shed virus in saliva, nasal secretions, and feces. Contact with feces or respiratory secretions is important in the transmission of infection among poultry. Between flocks, infection usually spreads due to movement of infected birds and the actions of humans in moving feedstuff, personnel, equipment, and vehicles into and from premises that are contaminated with infected feces or respiratory secretions. The duration that these viruses can survive in the environment depends on temperature and humidity conditions, but they may survive up to weeks in cooler and moister conditions.

Avian influenza viruses do not usually infect humans; however, several instances of human infections and outbreaks of avian influenza have been reported since 1997 (for more information, see “Basic Information About Avian Influenza” ). In 2003, influenza A (H7N7) infections occurred among persons who handled affected poultry and their families in the Netherlands during an outbreak of avian flu among poultry. More than 80 cases of H7N7 illness were reported (the symptoms were mostly confined to eye infections, with some respiratory symptoms), and one patient died (a veterinarian who had visited an H7N7 flu-affected farm). Although there was evidence of limited person-to-person spread of infection, sustained human-to-human transmission did not occur in this or other outbreaks of avian influenza. It is believed that most cases of avian influenza infection in humans have resulted from contact with infected poultry or contaminated surfaces. However, other means of transmission are also possible, such as the virus becoming aerosolized and landing on exposed surfaces of the mouth, nose, or eyes, or being inhaled into the lungs.

CDC RECOMMENDATIONS

The following interim recommendations are based on what are deemed optimal precautions for protecting individuals involved in the response to an outbreak of high pathogenic avian influenza from illness and the risk of viral reassortment (i.e., mixing of genes from human and avian viruses). The health risk to humans from low pathogenic avian influenza viruses is less well established, but is likely to be lower. Nonetheless, it is considered prudent to take all possible precautions to the extent feasible when individuals have contact with birds infected by any avian influenza virus as part of control and eradication activities.

Basic Infection Control

• Educate workers about the importance of strict adherence to and proper use of hand hygiene after contact with infected or exposed poultry, contact with contaminated surfaces, or after removing gloves. Hand hygiene should consist of washing with soap and water for 15-20 seconds or the use of other standard hand-disinfection procedures as specified by state government, industry, or USDA outbreak-response guidelines.
• Ensure that personnel have access to appropriate personal protective equipment (PPE), instructions and training in PPE use, and respirator fit-testing (detailed below).

Personal Protective Equipment

• Disposable gloves made of lightweight nitrile or vinyl or heavy duty rubber work gloves that can be disinfected should be worn. To protect against dermatitis, which can occur from prolonged exposure of the skin to moisture in gloves caused by perspiration, a thin cotton glove can be worn inside the external glove. Gloves should be changed if torn or otherwise damaged. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces.
• Protective clothing, preferably disposable outer garments or coveralls, an impermeable apron or surgical gowns with long cuffed sleeves, plus an impermeable apron should be worn.
• Disposable protective shoe covers or rubber or polyurethane boots that can be cleaned and disinfected should be worn.
• Safety goggles should be worn to protect the mucous membranes of eyes.
• Disposable particulate respirators (e.g., N-95, N-99, or N-100) are the minimum level of respiratory protection that should be worn. This level or higher respiratory protection may already be in use in poultry operations due to other hazards that exist in the environment (e.g., other vapors and dusts). Workers must be fit-tested to the respirator model that they will wear and also know how to check the face-piece to face seal. Workers who cannot wear a disposable particulate respirator because of facial hair or other fit limitations should wear a loose-fitting (i.e., helmeted or hooded) powered air purifying respirator equipped with high-efficiency filters.
• Disposable PPE should be properly discarded, and non-disposable PPE should be cleaned and disinfected as specified in state government, industry, or USDA outbreak-response guidelines. Hand hygiene measures should be performed after removal of PPE.

Vaccination with Seasonal Influenza Vaccine

• Unvaccinated workers should receive the current season’s influenza vaccine to reduce the possibility of dual infection with avian and human influenza viruses. There is a small possibility that dual infection could occur and result in reassortment. The resultant hybrid virus could be highly transmissible among people and lead to widespread infections. Vaccination of all residents of affected areas is not supported by current epidemiologic data.

Administration of Antiviral Drugs for Prophylaxis

• Workers should receive an influenza antiviral drug daily for the duration of time during which direct contact with infected poultry or contaminated surfaces occurs. The choice of antiviral drug should be based on sensitivity testing when possible. In the absence of sensitivity testing, a neuraminidase inhibitor (oseltamavir) is the first choice since the likelihood is smaller that the virus will be resistant to this class of antiviral drugs than to amantadine or rimantadine. For further information about the use of antiviral drugs for influenza, see “Prevention and Control of Influenza". Recommendations of the Advisory Committee on Immunization Practices (ACIP).” MMWR 2003; 52(RR08): 1-36. Available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5208a1.htm.

Surveillance and Monitoring of Workers

• Instruct workers to be vigilant for the development of fever, respiratory symptoms, and/or conjunctivitis (i.e., eye infections) for 1 week after last exposure to avian influenza-infected or exposed birds or to potentially avian influenza-contaminated environmental surfaces.
• Individuals who become ill should seek medical care and, prior to arrival, notify their health care provider that they may have been exposed to avian influenza. In addition, employees should notify their health and safety representative.
• With the exception of visiting a health care provider, individuals who become ill should be advised to stay home until 24 hours after resolution of fever, unless an alternative diagnosis is established or diagnostic test results indicate the patient is not infected with influenza A virus.
• While at home, ill persons should practice good respiratory and hand hygiene to lower the risk of transmission of virus to others. For more information, visit CDC’s “Cover Your Cough” website .

Evaluation of Ill Workers

• Workers who develop a febrile respiratory illness should have a respiratory sample (e.g., nasopharyngeal swab or aspirate) collected.
• The respiratory sample should be tested by RT-PCR for influenza A, and if possible for H1 and H3. If such capacity is not available in the state, or if the result of local testing is positive, then CDC should be contacted and the specimen should be sent to CDC for testing.
• Virus isolation should not be attempted unless a biosafety level 3+ facility is available to receive and culture specimens.
• Optimally, an acute- (within 1 week of illness onset) and convalescent-phase (after 3 weeks of illness onset) serum sample should be collected and stored locally in case testing for antibody to the avian influenza virus should be needed.
  

¹Respirators should be used in the context of a complete respiratory protection program as required by the Occupational Safety and Health Administration (OSHA). This includes training, fit-testing, and fit-checking to ensure appropriate respirator selection and use. To be effective, respirators must provide a proper sealing surface on the wearer's face. Detailed information on respiratory protection programs is provided at: www.osha.gov/SLTC/etools/respiratory/index.html and www.cdc.gov/niosh/topics/respirators/